Does the reporting of gastro-intestinal endoscopy meet the minimal terminology standard at King Edward VIII Hospital?

BACKGROUND: The Minimal Standard Terminology (MST) was developed to standardise endoscopic reporting. This study is aimed at assessing current reporting at a tertiary hospital and whether it meets this Minimal Standard Terminology.

METHOD: This was a retrospective observational study of upper endoscopy reports between January and December 2014. The data extracted were compared to the current reporting standard listed in the MST. To assess and grade the quality of reporting we developed a Gastrointestinal Reporting Score, which incorporates MST variables in addition to demographic details, indication for endoscopy, report legibility, sedation and the use of classification systems to describe pathology. Variables were classified as blank, partially complete or complete and assigned a score of 1-3. The reports were graded according to their overall score for all variables (Max 40) into Grade A (> 36), B (28-36) and C (< 28).

RESULTS: There were 100 patients of which 58 were female. Thirty-seven per cent were from the 60-75 year age group. Fiftyfour endoscopies were performed by trainee specialists. Junior and senior consultants performed 36 and 9 upper endoscopies respectively. Indications for upper endoscopy were stated in 51 reports. The use of pre-procedural sedation was not stated in 51 reports. Four reports were illegible; one was conducted by a junior consultant, two by a fourth year trainee specialist and one by an unknown endoscopist whose name was illegible. Common classification systems for oesophagitis, gastropathy features, ulcer characteristics, and ulcer location are not routinely used. Based on the Gastrointestinal Reporting Score there were no Grade A reports, 16 Grade B and 84 Grade C reports.

CONCLUSION: The MST is not routinely utilised in our setting and reports are incomplete. There is a need for optimal upper endoscopic reporting, incorporating the MST guidelines.